Levels of evidence in otolaryngology journals.

OBJECTIVE: To identify trends in clinical research and levels of evidence in otolaryngology journals. STUDY DESIGN AND SETTING: We reviewed all original research articles from 1993, 1998, and 2003, in 4 major otolaryngology journals. Levels of evidence were graded 1 (strongest) through 5 (weakest). RESULTS: Of 2584 total articles, 1924 (75%) were clinical research. During the study period, there was increased median sample size (from 22 to 30, P=0.06), more planned research (from 30% to 37%, P=0.023), more internal control groups (from 36% to 43%, P=0.011), and more articles with P values (from 26% to 45%, P<0.001) or confidence intervals (from 1.2% to 7.6%, P<0.001). Most evidence was level 4 (57%), but median levels increased slightly over time (P=0.027). Therapy articles had the weakest evidence (80% levels 3 to 5) and diagnostic test assessments had the strongest (75% levels 1 and 2). CONCLUSION: Although clinical research increased in quantity and quality, sample sizes were modest, most articles lacked controls, and confidence intervals were rare. Therapy articles would benefit from higher evidence levels. SIGNIFICANCE: By defining the current levels of evidence in otolaryngology journals, this overview should help guide future efforts.

Satisfaction and gender issues in otolaryngology residency.

OBJECTIVE: To evaluate the otolaryngology residency experience with attention to operative experience, career guidance, and gender. STUDY DESIGN AND SETTING: Otolaryngology residents were anonymously surveyed by mail about their residency experience. The 22-item survey was scored on a 5-point ordinal Likert scale. Responses were analyzed with respect to gender and postgraduate year (PGY) level. RESULTS: Complete surveys were returned by 261 otolaryngology residents (24% female). PGY level correlated with confidence that surgical skills were appropriate (P = 0.003), establishment of solid career network (P = 0.003), and confidence that surgical abilities are adequate for practice (P = 0.028). Female residents reported less confidence that surgical skills were appropriate (P = 0.050) and that surgical abilities were adequate for postresidency practice (P = 0.035). Women were encouraged to enter private practice more often (P = 0.012), were less likely to have a solid career network ( P = 0.025), and were less confident about being able to run their own practice (P = 0.036) CONCLUSIONS: Significant differences exist for several questions regarding surgical confidence and career issues, even after correction for PGY level.

Yantar, a conserved arginine-rich protein is involved in Drosophila hemocyte development.

To identify novel factors involved in Drosophila hematopoiesis, we screened a collection of lethal recessive mutations that also affected normal hemocyte composition in larvae. We present the characterization of the gene yantar (ytr) for which we isolated null and hypomorphic mutations that were associated with severe defects in hemocyte differentiation and proliferation; ytr is predominantly expressed in the hematopoietic tissue during larval development and encodes an evolutionary conserved protein which is predominantly localized in the nucleus. The hematopoietic phenotype in ytr mutants is consistent with a defect or block in differentiation of precursor hemocytes: mutant larvae have enlarged lymph glands (LGs) and have an excess of circulating hemocytes. In addition, many cells exhibit both lamellocyte and crystal cell markers. Ytr function has been preserved in evolution as hematopoietic specific expression of the Drosophila or mouse Ytr proteins rescue the differentiation defects in mutant hemocytes.

Tracheal resection with end-to-end anastomosis for benign tracheal stenosis.

To review our experience with tracheal resection with end-to-end anastomosis for tracheal stenosis, we performed a retrospective review at a tertiary-care academic medical center. Twenty-eight patients underwent circumferential tracheal resection with end-to-end anastomosis by 2 attending otolaryngologists from 1989 to 2002. Patients were excluded if they were under 12 years of age or if the surgical indication was tracheal or thyroid neoplasm. The indications for tracheal resection were postintubation stenosis (n = 9; 32%), posttracheotomy stenosis (n = 7; 25%), both postintubation and posttracheotomy stenosis (n = 9; 32%), external tracheal trauma (n = 2; 7%), and presence of a foreign body (n = 1; 4%). Two to 8 rings were resected. The follow-up periods ranged from 18 months to 13.5 years. The anastomotic success rate was 89% (n = 25). No patients died as a result of the procedure. We conclude that tracheal resection with end-to-end anastomosis is a relatively safe and reliable procedure for the treatment of tracheal stenosis in appropriately selected patients.

Recurrence rates after endoscopic sinus surgery for massive sinus polyposis.

BACKGROUND AND OBJECTIVES: Most studies on outcome after endoscopic sinus surgery (ESS) include patients with varying degrees of disease severity. Recurrence rates cited by those studies may not apply to the subset of patients with severe polyposis. Our aim is to provide reference information for recurrence rates and need for revision surgery in patients with severe disease. STUDY DESIGN, PATIENTS, AND METHODS: Review of patients with severe polyposis with a minimum Lund-McKay score of 16 and with a Kennedy computed tomography stage 3 or 4. Data collection included demographics, presence of asthma or documented allergy, history of previous surgery, extent of surgery, preoperative and postoperative management, recurrence rates, revision surgery rates, and follow-up. RESULTS: One hundred and eighteen records were reviewed. Fifty-nine (50%) patients had asthma, and 93 (79%) had documented allergy. All patients required extensive bilateral nasal polypectomy, complete anterior and posterior ethmoidectomy, and maxillary sinusotomy. One hundred (85%) also had frontal or sphenoid sinusotomy. Follow-up ranged from 12 to 168 (median 40) months. Seventy-one (60%) developed recurrent polyposis. Fifty-five (47%) were advised to undergo revision surgery, and 32 (27%) underwent surgery. History of previous sinus surgery or asthma predicted higher recurrence (P <.005, P <.001) and revision surgery rates (P =.02, P <.001). History of allergy also predicted recurrence and need for revision (P <.001, P <.001). CONCLUSIONS: Recurrence rates after ESS for severe polyposis are significant. In our study, patients with asthma are at higher risk of recurrence.

Chiari Type I malformation and upper airway obstruction in adolescents.

Chiari Type I malformation is characterized by cerebellar tonsil herniation through the foramen magnum. Manifestations may include new-onset upper airway obstruction. We describe two patients who had bilateral vocal cord paralysis and Chiari Type I malformation. These cases highlight the importance of suspecting a neurologic abnormality such as Chiari malformation in new-onset upper airway obstruction and/or bilateral vocal cord paralysis in adolescents in the absence of an obstructive lesion, though the development of cranial neuropathies or radiographic evidence may be delayed. Establishing a proper diagnosis is critical as Chiari I malformation can be treated with neurosurgical decompression, with possible improvement.

Outcomes in suction coagulator adenoidectomy.

OBJECTIVES: To assess the feasibility of suction coagulator adenoidectomy relative to adenoid size and to document patient-based outcomes and satisfaction with surgery. DESIGN: Historical cohort study. SETTING: Referral-based academic pediatric otolaryngology practice. PARTICIPANTS: Consecutive series of 118 children older than 3 years (mean age, 6.5 years) undergoing adenoidectomy alone. INTERVENTION: Video nasopharyngoscopy followed by suction coagulator adenoidectomy as part of routine clinical care. An outcome survey was completed by telephone. OUTCOME MEASURES: Duration of surgery, estimated blood loss, complications, parent satisfaction, and clinical outcomes. RESULTS: The distribution of preoperative adenoid grades as determined by nasal endoscopy were as follows: grade 2 (>or=33% to <66% choanal obstruction), 7%; grade 3 (>or=66% to <90% obstruction), 48%; and grade 4 (90%-100% obstruction), 45%. The mean (SD) surgical time of 10.5 (3.0) minutes was unrelated to adenoid grade (R = 0.014; P =.88). All blood loss was less than 15 mL (<5 mL for 67%), and the only complication was a loose tooth. The parents of 98 patients (83%) were contacted a mean of 30.4 days after surgery: 95 (97%) reported less-labored breathing, and 94 (96%) were satisfied with the surgical results. Only 5 patients (5%) required a follow-up visit within 30 days of surgery. CONCLUSIONS: Suction coagulator adenoidectomy proved safe and rapid, regardless of the adenoid size. Surgical outcomes were very favorable, with nearly all parents reporting satisfaction with the procedure and improvement in their child's breathing.